Trust Guideline for Capillary Blood Ketone Monitoring For Inpatients with Diabetes Mellitus Over 16 Years of Age

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1 For Use in: By: For: Division responsible for document: Key words: Name and job title of document authors: Name and job title of document author s Line Manager: Supported by: All clinical areas of the Trust Medical, and Nursing staff who have been specifically trained in blood ketone testing Inpatient Ward areas using the Precision Xceed Pro/FreeStyle Precision Pro meters (A&E, AMU L&M, CCC, EBDC, and Endocrine wards) Medical Division (Including Emergency) Blood Ketones. Blood glucose. Blood glucose monitoring, diabetes, ketoacidosis, hyperosmolar hyperglycaemic state Dr Tara Wallace, Consultant Endocrinology Sr Sandra Morris, Sr Esther Walden, Diabetes Inpatient Specialist Nurses Francesca Swords, Consultant Endocrinologist, Chief of Medicine Professor Jeremy Turner Clinical Guidelines Assessment panel Assessed and approved by the: If approved by committee or Governance Lead Chair s Action; tick here Date of approval: 11/07/2017 Ratified by or reported as approved to (if applicable): To be reviewed before: This document remains current after this date but will be under review To be reviewed by: Clinical Standards Group and Effectiveness Subboard 11/07/2020 Authors Reference and / or Trust Docs ID No: 7510 Version No: 3 Description of changes: Compliance links: (is there any NICE related to guidance) If Yes - does the strategy/policy deviate from the recommendations of NICE? If so why? Freestyle Precision Pro Meter added, Point of Care Testing (POCT) added, Quick Reference amended None N/A This guideline has been approved by the Trust's Clinical Guidelines Assessment Panel as an aid to the diagnosis and management of relevant patients and clinical circumstances. Not every patient or situation fits neatly into a standard guideline scenario and the guideline must be interpreted and applied in practice in the light of prevailing clinical circumstances, the diagnostic and treatment options available and the professional judgement, knowledge and expertise of relevant clinicians. It is advised that the rationale for any departure from relevant guidance should be documented in the patient's case notes. The Trust's guidelines are made publicly available as part of the collective endeavour to continuously improve the quality of healthcare through sharing medical experience and knowledge. The Trust accepts no responsibility for any misunderstanding or misapplication of this document. Available via Trust Docs Version: 3 Trust Docs ID: 7510 Page 1 of 8

2 Objective The aim of this guideline is: 1) To outline indications for blood ketone testing and interpretation of results. 2) To provide guidance to ensure accuracy when blood ketone testing. 3) To demonstrate standards for maintaining quality control. Rationale Diabetic ketoacidosis (DKA) is a major cause of mortality and morbidity in patients with type 1 diabetes. Over the past 20 years there has been no reduction in mortality rates which remain between 3.4 and 4.6% (1). Insulin deficiency, in combination with increased levels of stress hormones, stimulates lipolysis resulting in the production of acetylcoa (from fatty acids) which acts as the substrate for hepatic synthesis of ketone bodies (acetoacetate, beta-hydroxybutyrate, and acetone). In DKA the ratio of beta-hydroxybutyrate (-OHB) to acetoacetate increases from 1:1 to as much as 5:1 and -OHB is therefore the predominant ketone body contributing to the acidosis (2). Urine dipstick tests (Ketur-test, Combur 9 test ) have limited sensitivity and specificity because they do not detect -OHB they give only a semiquantitative measure of acetoacetate, react weakly with acetone and there is a time lag between ketones appearing in the blood and being excreted in the urine. As the acidosis resolves with treatment, -OHB is oxidised to acetoacetate. Under these circumstances urine tests may give the misleading impression that ketosis is not improving, and from a practical point of view there can be a problem obtaining urine samples from severely dehydrated patients at the time of presentation. Blood -OHB can be measured with a hand-held sensor - Precision Xceed Pro(PXP) / Freestyle Precision Pro meter using blood from a fingerprick test. The meter has been shown to be reliable with accuracy and precision that is well within acceptable clinical limits (3-5). The use of blood ketone tests based on the measurement of -OHB, rather than urine ketone tests, is now recommended in the Joint British Diabetes Society Inpatient Care Group national guideline for the management of DKA (6). When to measure ketones (-OHB): Blood ketones should be measured in any patient where there is clinical suspicion of decompensated Type 1 diabetes or in people with Type 2 diabetes who are acidotic at presentation. This includes: All patients with suspected new Type 1 diabetes. All patients with Type 1 diabetes who are unwell and/or have vomited. All patients with urine ketones +++ or Available via Trust Docs Version 3 Trust Docs ID: 7510 Page 2 of 8

3 Any patient with diabetes (Type 1 or Type 2) and acidosis i.e. ph <7.3 and/or bicarbonate <15mmol/L. In non diabetic patients if ketosis suspected (Cons/Endo SpR request only). How to measure blood ketones: The Precision Xceed Pro (PXP) / Freestyle Precision Pro meter should be used to measure blood ketone levels. The meter should be registered with the Point of Care Testing (POCT) Department and monthly external quality control tests must be performed according to Trust guidelines (Trustdocs Id 8679). Measurements should only be undertaken by appropriately trained staff as follows: Quick Reference Guide for Patient Testing 1. Put on non-sterile gloves. 2. Either ask the patient to wash their hands with soap and water then dry thoroughly, or swab the patient s finger with water and dry thoroughly. Do NOT use Mediwipes or alcohol to clean the finger. 3. Turn on meter. The meter display will self-test and show the date and time. 4. It will ask whether you want to perform 1- Patient Test or 2-Control Test. Select appropriate option. 5. Check that 2 quality control tests, using both the Medisense LO and HI solutions, have been performed in the last 24 hours. If the QC is required you will not be able to proceed to running a patient sample and the meter will be locked. 6. Carry out QC as/if necessary. 7. Once option has been selected you will be asked for Operator ID, press Scan to scan operator bar code. 8. Then scan Patient ID from patient wrist-band band, or medical notes if no wrist band available. If no patient ID is available enter the date and time as a 10 digit number using the keypad. e.g. 15 th December 2014 at 10:15am would be entered as Then scan Strip Lot (bar code found on each test strip). 10.If will then ask to Insert Strip. Ketone strips are in a purple foil pack. 11.Open test strips pack and insert strip into meter, leaving the foil in place. 12. Once strip is inserted properly the meter will read Strip Inserted. Remove foil. 13.The meter will then ask you to Apply Sample. Note: Do not lift the meter to view the display until after the test strip has been removed. Doing so may cause control solution/patient sample to drip onto the port protector or into the strip port, damaging the meter. 14.Place the sample on the end of the test strip. The strip will fill by capillary action. Allow the entire test area to fill with sample. 15. Once sufficient sample has been received the meter will read Sample Accepted. Available via Trust Docs Version 3 Trust Docs ID: 7510 Page 3 of 8

4 16. Once sample has been accepted the meter will read Analysing Sample and will commence a count-down and will beep for the last 4 seconds, then display the result. 17.If you wish to run another patient select option 1, and return to step 7. If finished press On/Off button. Training will be provided by Abbott representatives or Diabetes Inpatient Specialist Nurses and cascaded via Diabetes Link Nurses. Interpretation of blood ketones (B-OHB) B-OHB (mmol/l) Below 0.6 Action Normal ketone levels - continue to test blood glucose as normal. Treat for elevated glucose appropriately Follow sick day rules (See appendix 1) Ensure adequate fluid intake Consider giving additional short acting insulin Retest blood glucose and ketones in 1 hour Over 3.0 Risk of DKA Contact a doctor immediately Assess patient for signs of DKA, urgently check serum Na, K, bicarbonate and ph on venous blood gas analysis Refer to DKA guidelines: %20docs/CA1005DKApathwayFlowChart.pdf If patient is not in DKA, they still require additional insulin and fluid replacement by intravenous infusion (or additional subcutaneous doses on advice of diabetes team) Recheck ketone levels with blood glucose levels and document on chart Monitoring blood ketones in Diabetic Ketoacidosis is according to the Trust Guideline Blood ketones should be monitored hourly. Blood ketones can rise by 1-2 mmol/l per hour. With adequate treatment of DKA the blood ketone levels should fall by 0.5 mmol/l per hour. Management of Diabetic Ketoacidosis/Ketosis Available via Trust Docs Version 3 Trust Docs ID: 7510 Page 4 of 8

5 When ketosis has resolved (<0.6 mmol/l) If unable to eat or drink: switch to a variable rate intravenous insulin infusion. If well, able to eat and drink and biochemically stable (capillary ketones less than 0.6 mmol/l, ph over 7.3): convert to a subcutaneous regime at a mealtime (not evening meal). Continue intravenous insulin infusion until 30 minutes after subcutaneous short acting insulin has been given with meal (see Withdrawal of Variable Rate Intravenous Insulin Infusions Trustdocs Id 1357) Conversion from intravenous insulin to subcutaneous insulin should be managed by the Specialist Diabetes Team. If ketosis is not resolving, identify and treat the reasons for failure to respond. This situation is unusual and requires senior and specialist input These are broad recommendations and if you are concerned about a patient s clinical condition or blood ketone levels the patient should be referred for early review to the diabetes team. Contact details During working hours please inform the Diabetes Inpatient Specialist Nurses (bleep ****) Monday to Friday to Out of hours until and weekends Endocrine doctors (Bleep ****). For emergency advice overnight - Consultant on call via switchboard. Clinical audit standards All patients who are suspected of having DKA should have a blood ketone measurement taken. All patients with a blood ketone measurement above 3.0mmol will be treated according to the national DKA guidelines. Weekly ketone quality control checks will be performed. Audit can be undertaking with a retrospective review of case notes and observation charts Broad Recommendations Blood ketones must be measured in unwell patients with diabetes who are suspected to have acidosis using the Precision Xceed Pro/ Freestyle Precision Pro meter. In patients with Diabetic Ketoacidosis or ketosis, blood ketone measurements should be used to guide treatment and monitor response to treatment. Ward areas in NNUH using the Precision Xceed Pro/ Freestyle Precision Pro meters are A&E, AMU L&M, CCC, Cringleford, Docking and Langley wards. Available via Trust Docs Version 3 Trust Docs ID: 7510 Page 5 of 8

6 Summary of development and consultation process undertaken before registration and dissemination This document was developed after discussions between the Pathology services and Diabetes department, Assistant Director of Nursing for Medicine and the Practice Development and Education Department.This version has been endorsed by the Clinical Guidelines Assessment Panel. Distribution list/ dissemination method Elsie Bertram Diabetes Centre Trust Intranet References: 1. Basu A, Close CF, Jenkins D, Nattrass, Wright AD. Persisting mortality in diabetic ketoacidosis. Diab Med 1993; 10: Stephens JM, Sulway MJ, Watkins PJ. Relationship of blood acetoacetate and 3- hydroxybutyrate in diabetes. Diabetes 1971; 20: Byrne HA, Tieszen KL, Hollis S, Dornan TL, New JP. Evaluation of an electrochemical sensor for measuring blood ketones. Diabetes Care 2000; 23: TM Wallace, NM Meston, SG Gardner, DR Matthews. The hospital and home use of a 30-second hand-held blood ketone meter: guidelines for clinical practice Diabetic Medicine 2001; 18: Wallace TM, Matthews DR (2004) Recent advances in the monitoring and management of diabetic ketoacidosis. Q J Med Vol 97 p Joint British Diabetes Societies Inpatient Care Group, (2010), The Management of Diabetic Ketoacidosis in Adults NHS Diabetes. Further Reading: 1. Bektas F, Eray O, Sari R, Akbas H. Point of care testing of diabetic patients in the emergency department. Endocr Res 2004;30: Clement S et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care 2004; 27: Dhatariya K. Editorial. Diabetic Ketoacidosis. Brit Med J 2007 (334): DoH Medical Directorate Safety Action Bulletin No.65 November Lancing Devices for Multi-patient capillary Sampling: avoidance of cross infection by correct selection and use. 5. Sampson MJ, Crowle T, Dhatariya K, Dozio N, Greenwood RH, Heyburn PJ, Jones C, Temple RC, Walden E. Trends in bed occupancy for inpatients with diabetes before and after the introduction of a diabetes inpatient specialist nurse service. 6. Diabetic Med. 2006; 23: Dhatariya K. Blood ketones - measurement, interpretation, limitations and utility in the management of diabetic ketoacidosis. Review of Diabetic Studies 2016;13 (4): Available via Trust Docs Version 3 Trust Docs ID: 7510 Page 6 of 8

7 7. Umpierriez GE, Kortytkowski M. Diabetic emergencies - ketoacidosis, hyperglycaemic hyperosmolar state and hypoglycaemia. Nature Reviews Endocrinology; 2016;12(4): Dhatariya,K K; Nunney,I; Higgins,K; Sampson,M J; Iceton,G. A national survey of the management of diabetic ketoacidosis in the UK in Diabet Med 2016;33(2): Available via Trust Docs Version 3 Trust Docs ID: 7510 Page 7 of 8

8 Appendix 1 Sick Day Rules Adults with Diabetes Undergoing Surgery and Elective procedures (Trustdocs Id 1276) (page 34). What should I do if I am unwell? NEVER stop taking your insulin or tablets illness usually increases your body s need for insulin TEST your blood glucose level every 2 hours, day and night TEST your urine for ketones every time you go to the toilet or your blood ketones every 2 hours if have the equipment to do this DRINK at least 100 mls water/sugar free fluid every hour you must drink at least 2.5 litres per day during illness (approximately 5 pints) REST and avoid strenuous exercise as this may increase your blood glucose level during illness EAT as normally as you can. If you cannot eat or if you have a smaller appetite than normal, replace solid food during illness, with one of the following: o 400 mls milk o 200 mls carton fruit juice o mls non-diet fizzy drink o 1 scoop ice cream Available via Trust Docs Version 3 Trust Docs ID: 7510 Page 8 of 8